Latest reports, citations, and penalties from CMS data
Inspectors observed 26 medication administration opportunities and documented two critical errors involving life-saving medications....
The incident had immediate physical consequences....
The violations affected at least four residents requiring daily injections for diabetes management and blood clot prevention....
## Unlicensed Oxygen Therapy Administration The most serious violations involved four residents receiving oxygen therapy without proper medical authorization....
"He was unable to reach the call light from his position on the shower chair," according to the federal inspection report....
This violation created unnecessary risk of head trauma during seizure activity....
## Food Safety and Temperature Violations The most widespread issue involved food service failures affecting residents across the facility....
The resident's medical records documented diagnoses including depression and a history of sexual behaviors related to psychiatric illness....
The resident's initial smoking safety evaluation from 2022 incorrectly indicated he did not use tobacco, leading to the absence of necessary safety protocols....
This represents a critical breakdown in the facility's internal oversight systems designed to ensure quality care for residents....
The resident required immediate emergency transportation and received two units of blood at the hospital after being diagnosed with iron deficiency anemia....
The nursing assistant told her to wait because breakfast trays were arriving....
The 89-year-old resident with severe cognitive impairment lay sleeping nearby while the prescription medications remained easily accessible....
When questioned, LVN 6 was unsure if there was an order for the oxygen therapy....
According to the visitor's account, a staff member responded by yelling at the resident: "We hear you....
## Pattern of Narcotic Tracking Discrepancies Federal inspectors uncovered a concerning pattern of medication tracking failures spanning several months....
The specific nature of the medication violations was documented as part of complaint investigation AL00050173....
The facility obtained the X-ray on July 11, 2024, and results showed "calcaneus erosion consistent with osteomyelitis" - a serious bone infection of the heel....
The most severe case involved a resident who missed 21 doses of gabapentin over six days without any physician notification....
The violations occurred despite facility policies requiring staff to report suspected theft or misappropriation to the State Survey Agency....